Krankenhaus-Infektions-Surveillance-System (KISS)
Hospital Infection Surveillance System
ONKO-KISS Protocol:
Healthcare-associated Infection Surveillance in
Hematology/Oncology Wards
DRAFT VERSION
DRAFT VERSION
2
ONKO-KISS: Protocol on HAI Surveillance in hematology/oncology wards © 2012 National Reference Center
for the Surveillance of Nosocomial Infections
www.nrz-hygiene.de
This draft version is not approved for citation or application.
DRAFT VERSION
3
Table of Contents: 1. Introduction ........................................................................................................................................ 4
2 Goals of ONKO-KISS .......................................................................................................................... 5
3. Requirements for participation in ONKO-KISS by hematology/oncology units and duties of
KISS institutions .................................................................................................................................... 6
4. Methods .............................................................................................................................................. 7
4.1 Patient data collection ............................................................................................................................... 7
4.2 Infection data collection ............................................................................................................................ 7
4.3 Calculation of reference data ................................................................................................................... 7
4.4 Comparing infection rates ........................................................................................................................ 8
5 General definition principles by the CDC and specified definitions ............................................. 9
6 Definitions ......................................................................................................................................... 11
6.1 Primary Bloodstream Infection (BSI) .................................................................................................... 11
6.2 Pneumonia ............................................................................................................................................... 12
6.2.1 Definitions for fungal pneumonia and Legionella pneumonia (Legionnaire’s disease) ......... 13
7. Surveillance specifications ............................................................................................................ 15
7.1 Patient data collection forms for ONKO-KISS, ONKO-KISS_PAED and ONKO-KISS_AL ......... 15
7.1.1 ONKO-KISS and ONKO-KISS_PAED .......................................................................................... 19
7.1.2 Specifications for ONKO-KISS_AL (for acute leukemia) ........................................................... 19
7.2 Patient progress form ............................................................................................................................. 21
7.3 BSI pathogen resistance surveillance .................................................................................................. 21
8. Documentation specifications ....................................................................................................... 22
8.1 Patient information form ......................................................................................................................... 22
8.2 Abbreviations of underlying illnesses ................................................................................................... 22
8.3 ICD-10 codes for acute leukemias ........................................................................................................ 22
8.4 Pathogen abbreviations .......................................................................................................................... 23
8.5 Examples for determining neutropenia as a surveillance period ...................................................... 27
9 References ........................................................................................................................................ 29
10 Appendix ......................................................................................................................................... 30
10.1 Patient data collection form for ONKO-KISS and ONKO-KISS_PAED: Patients with bone
marrow or blood stem cell transplantations (BMT, PBSCT, cord blood) ............................................... 30
10.2 Patient data collection form for ONKO-KISS_AL: Patients with AML or ALL without primary
transplantation and receiving standard chemotherapy............................................................................. 31
10.3 Data collection forms for pneumonia .................................................................................................. 32
10.4 Progress form for infection surveillance, Hematological /Oncological Units ................................ 35
11 Legal Notice .................................................................................................................................... 36
DRAFT VERSION
4
1. Introduction
It has been known for over twenty years that the continuous, systematic collection, analysis
and interpretation of data relevant to nosocomial infections as well as feedback for doctors
and nurses can reduce the frequency of these infections. This kind of internal quality
assurance is known as surveillance. Data from one hospital are more valid and more
effective when they are compared with those from other hospitals. The frequency of infection
at one station or ward can only be determined in context with data from other stations and
departments. In order to avoid false conclusions, comparisons are only possible when
identical methods of data collection with fixed diagnostic definitions are used.
The Hospital Infection Surveillance System (German: Krankenhaus-Infektions-Surveillance-
System = KISS) was launched in 1997 by the National Reference Center for the Surveillance
of Nosocomial Infections (German: Nationales Referenzzentrum = NRZ). ONKO-KISS, a
module for the surveillance of healthcare-associated infections in patients over 16 years of
age with bone marrow or blood stem cell transplantations, was developed in late 2000. A
similar module, ONKO-KISS_PAED, was launched in 2003 to include patients under 16 or in
pediatric wards. ONKO-KISS_AL, similarly, was started in 2005 to include patients over 16
with acute leukemia (AML or ALL).
The project is based at the Institute for Environmental Medicine and Hospital Hygiene
(German: Institut für Umweltmedizin und Krankenhaushygiene = IUK) at the University Clinic
Freiburg.
DRAFT VERSION
5
2 Goals of ONKO-KISS
Patients receiving either autologous or allogeneic bone marrow or blood stem cell
transplantation have one of the highest rates of infection of all oncology patients, especially
in the neutropenic phase. Because patients with autologous and allogeneic transplantations
have varying infection rates, the data for these groups are evaluated separately.
Bloodstream infections (BSI) and pneumonia are among the most frequent and most severe
healthcare-associated infections (HAI). For this reason, it makes sense to continuously track
healthcare-associated bloodstream infections and pneumonias in these patients, especially
in the neutropenic phase.
This surveillance protocol has the primary goal of providing participating institutions with
necessary specifications and definitions. This creates proper conditions for standardizing
data collection and data analysis. In this way, reference data can also be made available for
benchmarking and internal quality assurance.
Acute leukemia patients being treated with chemotherapy are also especially susceptible to
infection in the neutropenic phase and are included for this reason in ONKO-KISS.
ONKO-KISS, ONKO-KISS_PAED and ONKO-KISS_AL are evaluated separately. Reference
data are generated for ONKO-KISS and ONKO-KISS_AL. The reference data from ONKO-
KISS serve as a reference for ONKO-KISS_PÄD.
Other hematology or oncology departments can use the definitions contained within this
protocol to perform surveillance of HAIs. Analogical evaluation of surveillance data makes it
possible for these departments—after taking their unique situations into account—to
benchmark themselves in the reference data.
The basis for the following protocol is the (partially modified) CDC definitions for healthcare-
associated bloodstream infection and pneumonia surveillance. Special definitions apply for
the surveillance of pneumonia caused by aspergilli or legionella.
DRAFT VERSION
6
3. Requirements for participation in ONKO-KISS by
hematology/oncology units and duties of KISS institutions
Participating facilities must fulfill the following requirements:
Treatment of at least 20 patients with bone marrow or blood stem cell
transplantations annually (for ONKO-KISS_AL, at least 20 patients with AML or ALL
must be treated with chemotherapy annually)
Written agreement of ward head to KISS participation and to data transfer via
webKess
Employment of full-time infection control personnel or hygiene specialists by the
participating hospital. Infection control personnel are the most important contact
partners for ONKO-KISS and are responsible for organizing surveillance in the
participating departments and wards.
Registration of participation with the IUK Freiburg
Participation in an introductory course in surveillance by the IUK. A date for the
introductory course will be made with each new participant before the start of
surveillance.
Registration for webKess by the participating ward
Regular transfer of collected data to the NRZ via webKess
Readiness of infection control personnel to participate in validation measures in HAI
diagnosis; e.g. during the annual ONKO-KISS participant meeting in Freiburg
Readiness to employ appropriate internal quality assurance measures upon relevant
surveillance results
Agreement to use the fixed definitions given here for HAI diagnosis and agreement to
inform attending physicians
Strict use of the specifications found in this protocol and readiness to discuss open
questions. In addition to those data required by this protocol, participating
departments are free to include other data that are relevant for quality management.
The NRZ promises participating departments to:
Provide advice and expert support during surveillance
Handle each ward’s data strictly confidentially
Send standardized infection data as reference data to participant yearly
Advise them on the implementation of surveillance results for quality management
DRAFT VERSION
7
4. Methods
4.1 Patient data collection
All patients who receive a bone marrow transplantation (BMT) or peripheral blood stem
cell transplantation (PBSCT) or a cord blood transplantation should be kept under
surveillance during the neutropenic phase.
The following applies for ONKO-KISS_AL: all patients who are treated with
chemotherapy for acute leukemia are included in surveillance during the neutropenic
phase.
A patient data collection form must be completed for all neutropenic patients
Basic data for each patient should be documented, such as name, birthdate, sex, date of
admission or transfer, start and end of neutropenic phase or phases, illness (if
applicable), type of transplantation (or phase of chemotherapy for ONKO-KISS_AL) and
type of venous access, as well as any length of stay in intensive care.
If a central venous catheter is present, additional information about its location and type
as well as about the use of remanent skin disinfectant and/or patches should be included.
4.2 Infection data collection
Surveillance should take place during the neutropenic phase. During the neutropenic
phase, all healthcare-associated bloodstream infections and pneumonias should be
recorded in the patient data collection form. For each recorded case of pneumonia, a
special infection data collection form should be completed with information about
diagnosis.
4.3 Calculation of reference data
The following infection rates are calculated (incidence density: total number of cases in
reference to 1000 neutropenia-days):
Bloodstream infection rate:
Total BSI
———————x1000
Neutropenia-days
Pneumonia infection rate:
Total cases of pneumonia
———————x1000
Neutropenia-days
DRAFT VERSION
8
Starting in 2011, the infection rates for BSI and pneumonia per 100 patients have been
available publicly online. Until then, the rates had only been available to ONKO-KISS
participants.
4.4 Comparing infection rates
Standardized infection rates are calculated by the NRZ with the collected data of all
participating departments and made available as reference data. These figures are available
online on the NRZ web site. The infection rates of each specific ward are kept confidential
and transferred only to that ward.
The reference data make it possible to benchmark one’s own data against the pooled data of
all participating departments. However, comparison is only possible when all factors are
taken into account. This comparison is only possible when other relevant factors are taken
into account. However, the Institute for Environmental Medicine and Hospital Hygiene
provides an aid for reference data interpretation.
Changes in infection rates on one station may be observed over time and may point to
infection control issues that should be investigated further. Starting in 2011, participants have
been provided with a “smoothed curve” once per year via webKess in order to better
recognize changes in the course of surveillance.
Surveillance results must be presented yearly to the wards or departments in which
surveillance has taken place.
DRAFT VERSION
9
5 General definition principles by the CDC and specified definitions
A diagnosis of infection for the purpose of surveillance relies on a combination of clinical
symptoms, and laboratory and other supporting data (e.g., X-rays, microbiological evidence),
weighted differently according to the type of infection.
An infection is defined as healthcare associated when it was not apparent or in the
incubation stage at admission.
HAI can be caused by endogenous or exogenous pathogens.
A colonization (presence of disease agents on skin or mucous membranes, in open
wounds, in excretion or secretion) is not an infection.
It is important to note that these epidemiological definitions are not intended for day-to-day
infection diagnosis by attending physicians, but instead for HAI surveillance. The definitions
should make it possible for infection control personnel to recognize a HAI based on patient
records. They provide a structure into which patients can be classified in order to provide the
best possible comparison between departments or wards.
These definitions are not appropriate for making decisions about treatment or therapy.
Specific definitions for ONKO-KISS
During surveillance of the neutropenic phase, as is analogous to CDC criteria, BSI and
pneumonia are only recorded when they were not apparent or in incubation at the start of
neutropenia.
BSI surveillance:
CDC definitions apply. Because nearly all neutropenic patients have a CVC of one type or
another, healthcare-associated BSIs are per se defined as associated with devices.
It is characteristic in neutropenic patients who have received a bone marrow or blood stem
cell transplantation that blood cultures are negative because of early antibiotic therapy. In
order to assure simple classification, only laboratory-confirmed BSIs according to CDC
criteria are considered HAIs.
Pneumonia surveillance:
The modified criteria for immune-suppressed patients by Carlisle, P., et. al. (1993) apply for
healthcare-associated pneumonia surveillance.1 These were also the basis for a four-year
surveillance period (1997 to 2001) of HAI in the Inner Medicine I (Hematology, Oncology)
ward of the University Clinic Freiburg.2 A multi-year pilot phase within ONKO-KISS showed
DRAFT VERSION
10
that the CDC definitions for healthcare-associated pneumonia in immune-suppressed
patients are not appropriate for surveillance within ONKO-KISS. At the same time, the
appropriateness of Carlisle’s definitions has been confirmed.
Special definitions for pneumonia caused by fungus or Legionella have been in use since
2004 because these types of pneumonia could not be recorded with the above-named
criteria (Carlisle).
The definition for pneumonia was adjusted in order to include pneumonia caused by fungus
in 2010 following EORTC criteria for the definitions of invasive fungal infections (De Pauw et
al, Clin Infect Dis 2008; 46:1813-21).
The definition for pneumonia caused by Legionella is the CDC definition for atypical
pneumonia in patients with immunodeficiency or suppression.
DRAFT VERSION
11
6 Definitions
Following the Guidelines of the Infectious Diseases Society of America (IDSA) from
19973, the definition for neutropenia is:
a neutrophil count of <500 cells/mm3, or a count of <1000 cells/mm3 with a predicted
decrease to <500 cells/mm3
or:
total leucocytes < 1000/mm3.
The neutropenic phase is ended when a patient has not been neutropenic according to
the above definition for three consecutive days (for examples, see 9.1).
6.1 Primary Bloodstream Infection (BSI)
Laboratory confirmed BSI has to fulfill at least one of the following criteria:
Either:
1. Patient has a recognized pathogen* cultured from 1 or more blood cultures and organism
cultured from blood is not related to an infection at another site. Catheter-associated BSI is
classified as a primary BSI also when there are signs of infection at the site of insertion.
and/or:
2. One of the following: fever (>38oC, rectal or oral), chills, or hypotension
and one of the following:
Common skin contaminant** is cultured from 2 or more blood cultures drawn on
separate occasions and signs and symptoms and positive laboratory results are not
related to an infection at another site.
Positive blood test for antibodies and the pathogen is not related to an infection at
another site.
* Evidence of Aspergillus spp. is always considered contamination.
**Diphtheroids [Corynebacterium spp], Propionibacterium spp, coagulase-negative
staphylococci [including S epidermidis], etc.
DRAFT VERSION
12
6.2 Pneumonia
Pnuemonia in immune-suppressed patients
must fulfill one of the following criteria.
Either:
Fever (>380C, measured rectally or orally) and new or progressive and persistent infiltrate in
radiological diagnosis*
and/or:
at least two of the following:
Sputum production
Coughing
Dyspnea
Rhoncus or crackling sounds
Leukocytes in sputum microscopy
Pleural rub
*I.e., a radiologically proven infiltrate that does not appear in a second examination (with a
multi-day interval) is not adequate.
DRAFT VERSION
13
6.2.1 Definitions for fungal pneumonia and Legionella pneumonia
(Legionnaire’s disease)
Definition of fungal pneumonia
Demonstrated opportunistic fungal pneumonia
Histo/cytopathology: Hyphae in needle aspiration/biopsy material (not mucous membrane) +
damage to tissue (microscopy or imaging)
or
Blood culture: Fungus from tissue/biopsy materials from primarily sterile body parts with
evidence indicating pneumonia
NOT: Bronchoalveolar lavage (BAL); NOT: Evidence of Aspergillus spp. in blood cultures
Probable opportunistic fungal pneumonia
At least one of the following patient characteristics:
Current or recent neutropenia (< neutrophils/mm3) for >10 days
Status post allogeneic BSCT
Corticosteroid > 3 weeks (average dose 0.3 mg/kg/d prednisone equivalent) with the
exception of patients with allergic bronchopulmonary aspergillosis.
Treatment with further T-cell immune suppressants (e.g., Cyclosporin, TNF- blocker,
specific monoclonal antibodies, nucleoside analogues) within the last 90 days
Severe congenital immunodeficiency
And
At least one of the follow mycological findings
Direct evidence: Evidence of fungus in respiratory secretion (Sputum, BAL, brush
biopsy) by
Fungus culture (Aspergillus, Fusarium, Mucor, Absidia, Rhizopus spp., etc)
Evidence of fungus components indicating fungal infestation
Indirect evidence:
Positive evidence of aspergillus antibodies (Galalctomannan-AG) from BAL,
plasma or serum
And
At least one of the following findings in thoracic CT: (consistent with mycological
findings and in a temporal relationship to the course of infection):
Thick nodules with or without halos
Air crescents
Cavity development
Modified according to EORTC criteria for invasive fungal infections (De Pauw, et al., Clin
Infect Dis 2008; 46: 1813-21)
DRAFT VERSION
14
Definition of Legionella pneumonia (Legionnaire’s disease)
At least one of the following signs is found in two or more thoracic X-rays (In patients
without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome,
bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease),
one definitive chest radiograph is acceptable):
New or progressive and persistent infiltrate
Consolidation
Cavity development
Pneumatoceles, in infants <1 year old
and at least one of the following:
Fever (>38C) with no other recognized cause
For adults >70 years old, altered mental status with no other recognized cause
New onset of purulent sputum
or change in character of sputum (color, consistency,
smell)
or increased respiratory secretions or increased suctioning requirements
New onset or worsening cough or dyspnea or tachypnea
Rales
or bronchial breath sounds
Worsening gas exchange (increased oxygen requirements, or increased ventilator
demand)
Hemoptysis
Pleural pain
and at least one of the following:
Cultured evidence or micro-immunofluoresence (IF test) for Legionelle spp. from
respiratory tract secretion or tissue
Evidence of L. pneumophila SG1 antigens in urine
Quadrupling of L. pneumophila antibody titer to >1:128 in serial serum tests
Source: CDC definitions for pneumonia in immunocompromised patients, specified for
Legionella pneumonia (Legionnaire’s disease)
DRAFT VERSION
15
7. Surveillance specifications
7.1 Patient data collection forms for ONKO-KISS, ONKO-KISS_PAED and
ONKO-KISS_AL
Participants submit their ONKO-KISS data for evaluation via webKess. In order to enter their data,
participants must register for webKess with the NRZ in Berlin. An abbreviation for the hospital will be
provided by the NRZ.
Each module (ONKO-KISS, ONKO-KISS_PAED and ONKO-KISS_AL) must be registered separately.
Written registration at the NRZ in Berlin with consent of the appropriate ward is the final step.
The Internet address of webKess is www.webKess.de.
Online problems can be resolved by calling the NRZ at 030 450 570022 or by writing an email to kiss-
Reference data are prepared once per year by the NRZ in Berlin. In order to make sure the reference
data reflect the most recent surveillance, ONKO-KISS participants are required to complete their
surveillance data from one calendar year within the first six weeks of the next year.
The definition of a BSI for surveillance changed in 2011. Previously, it was possible to record a case of
BSI with a single culture of skin flora. Because of this substantial change, reference data were cut off
at the end of 2010 and restarted in January 2011. Data can only be evaluated before 2010 or after
2011.
Participants can evaluate their own data at any time in webKess.
Advice on surveillance for individual cases is available from the IUK in Freiburg.
Data should be recorded on the collection form and transferred to webKess when the patient is
discharged. The system automatically gives each patient an ID that should be noted on the chart in
order to clearly attribute the data.
Patients can be under surveillance in multiple wards, but the NRZ only evaluates hospitals as a whole.
After consulting with the NRZ, it is possible for hospitals with more than one participating ward to
receive separate abbreviations.
Sex, age and underlying disease are collected as master data.
Type of venous access is also recorded.
If two kinds of venous access are present, only the most risky in relation to infections is
recorded. Usually, the risk of infection is lowest with a PVC, followed by ports, Hickman
catheters and CVCs.
If a patient has a CVC, the site of the CVC is also recorded, and if the CVC is coated (with
silver or antibiotics) or not. In addition, the use of remanent skin disinfectants during the
installation or maintenance of the venous access is also documented. Octenidin (Octeniderm,
Octenisept) and Chlorhexidin (Skinsept F) have remenence effects. The use of patches or
DRAFT VERSION
16
bandages with remanent active ingredients (e.g., Biopatch or Tegaderm CHG/Chlorhexidin) is
also recorded.
Surveillance is performed during the neutropenic phase or phases.
The beginning and ending of all neutropenic phases is documented, as is if the patient was
neutropenic at admission to the ward.
The number of neutrophils or the total number of leukocytes measured at a set time (e.g. 7 a.m.)
is recorded.
Neutropenia (neutrophil count of <500 cells/mm3 or total leucocytes < 1000/mm
3) must be present
for two consecutive days to begin the neutropenic phase. The neutropenic phase is ended as
soon as the neutrophil count is >500 cells/mm3 or total leucocytes > 1000/mm
3 for three
consecutive days.
If a patient is no longer neutropenic for one or maximum two consecutive days during a
neutropenic phase, then these days are counted as neutropenia-days (see 8.4 for examples).
Because some patients develop multiple neutropenic phases, patients must be kept under
surveillance regarding their neutrophil or total leukocyte counts until they are transferred or
discharged.
The reason for ending surveillance is also documented: end of neutropenic phase, transfer or
discharge of patient while neutropenic, or death of patient.
If a patient was on an ICU during the neutropenic phase and if he or she was ventilated by
intubation should be recorded. Days in intensive care are counted as neutropenia-days and HAIs
appearing there should be recorded.
Quinolone prophylaxis (with Levofloxacin or Ciprofloxacin, for example) should be recorded if
performed. A “Yes” for prophylaxis means that quinolone was given BEFORE the start of fever
and BEFORE the first therapeutic antibiotics. Information must also be provided if quinolone
prophylaxis is NOT performed: either this is appropriate for a patient’s prophylactic regime or the
patient is already on antibiotics.
Infection surveillance
Infections are to be documented after the second day of the neutropenic phase; infections are to
be documented up to and including the second day after the neutropenic phase (see 8.4 for
examples).
When a BSI or pneumonia appears during the neutropenic phase, the data of the infection and the
proven pathogen are both recorded. Up to 4 pathogens can be recorded per infection. The
pathogens are listed in order of presumed etiological relevance.
Specifications for BSI surveillance
The start date for a BSI is the date on which the blood culture was taken. If the same pathogen is
found more than once, then only one case of BSI is recorded. If a different pathogen is found in a later
DRAFT VERSION
17
culture, that does not automatically mean that a second case of BSI is present. A second case is only
recorded if the previous BSI had already ended.
BSIs are ended when all infection parameters are within normal limits and the patient has been
clinically stable for three days, independent of whether antibiotic therapy has ended or not.
Coagulase-negative staphyloccci, corynebacteria and propionbacteria are considered skin
contaminants; Streptococcus mitis is considered a disease agent.
According to current CDC definitions, BSIs in which only a skin contaminant and not a disease agent
are found should only be included in surveillance when the pathogen was found in at least two blood
cultures taken separately.
Aspergilla are always considered contamination.
Specifications for pneumonia surveillance
The start date for pneumonia is that on which the first specific sign of pneumonia appeared. The
following signs apply as specific for pneumonia: sputum production, cough, rhoncus or crackling
sounds, leukocytes in sputum microscopy and pleural rub, as well as an X-ray or CT examination with
indications for pneumonia. Fever and dyspnea are not signs specific to pneumonia.
Pneumonia may be included in surveillance in three different ways:
Variant 1
Surveillance by fever and two verifications by X-ray or CT (without a time restriction between the
first and second verification). If the first verification is an examination with the suspicion of pneumonia
and is confirmed later, then the first verification is considered a positive verification.
Fever and one positive X-ray exam must be present at the same time (within a period of three days).
Variant 2
Surveillance by clinical signs and symptoms
If surveillance should take place based only on clinical signs and symptoms (not including fever or
dyspnoe), then at least two of these must be present for at least three days. Clinical signs include:
sputum production, cough, rhoncus or cracklings ounds, leukocytes in sputum microscopy and pleural
rub. In these (rare) cases, pneumonia can only be recorded if the patient was not X-rayed. If there is a
negative x-ray or CT result available, the infection is not considered pneumonia.
Varient 3 (most common case)
Surveillance by fever, one verification by X-ray and CT and two clinical signs or symptoms
The clinical signs or symptoms for pneumonia must present simultaneously for at most ten days.
Clinical signs include: Dyspnoe, sputum production, cough, rhoncus or crackling sounds, leukocytes in
sputum microscopy and pleural rub. In the same time period, fever must be present once and a
positive X-ray result must be available.
DRAFT VERSION
18
Whether the radiological verification took place by X-ray or by CT must be recorded.
If patient material was examined microbiologically and if a pathogen could be confirmed in this
way must be recorded.
Because the definitions for pneumonia surveillance, especially those for fungal pneumonia or
Legionella pneumonia (Legionnaire’s disease), are rather difficult to implement, all definition
criteria are asked about for all cases of pneumonia. In this way, it is possible to see which criteria
were important in making the diagnosis. A special form for each kind of pneumonia (normal,
fungal, Legionella) is available in webKess.
After the neutropenic phase
Infection surveillance ends after the end of the neutropenic phase.
Patients are observed in regard to further neutropenic phases until the end of their stay on the
ONKO-KISS ward.
The reason for ending surveillance (discharge, transfer, or death) must also be documented.
After the end of surveillance, patient data is entered by the participants into webKess.
General specifications
Facilities new to ONKO-KISS have the opportunity to record only BSI for a certain period,
upon approval by the project headquarters in Freiburg. The prerequisite is that the relevant
data are being recorded on the ward.
We recommend performing surveillance once or twice a week.
DRAFT VERSION
19
7.1.1 ONKO-KISS and ONKO-KISS_PAED
Those patients who have received bone marrow transplantation (BMT) or peripheral blood stem
cell transplantation (PBSCT) or cord blood transplantation on the participating ward are included in
surveillance. Only children with allogeneic transplants are included in ONKO-KISS_PAED. ONKO-
KISS includes patients older than 16; ONKO-KISS_PAED includes all children under 16 and those
young adults still being treated in pediatrics.
ONKO-KISS and ONKO-KISS_PAED data are collected and evaluated in separate databanks.
A unique ID number is assigned to each patient data form when the data is entered into webKess.
This number should be noted on the form in order to correctly correlate the data to the patient.
Patient data forms remain with participants.
If two underlying illnesses are both present, enter the illness for which the transplantation or
transplantation is relevant. If this is not possible, check AND.
Both the degree of illness and the type of transplantation or transplantation are recorded.
“Early stage” includes all patients with complete remission of their illness, all patients who
received transplantation directly after their diagnosis, and all CML patients in the first chronic
stage. “Late stage” includes all relapsed patients, patient in second remission or the second
chronic phase, or in any further stage, e.g. second or third recidivism.
If a patient receives transplantation twice during the same stay in the participating ward, only one
data collection form is filled out, and the more invasive procedure is recorded. If a patient receives
multiple transplantations and is transferred out of the participating ward and back again, then a
new data collection form should be filled out for each transplantation.
Patients are recorded by the hospital where they receive transplantations and not in other
hospitals they were in for staging or chemotherapy, even when the patients may have been
neutropenic.
7.1.2 Specifications for ONKO-KISS_AL (for acute leukemia)
All patients over 16 years of age with acute leukemia (AML and ALL) that have not received a
primary transplantation and have been treated with chemotherapy are to be included in
surveillance. Relapsed patients who received allogeneic transplantations prior to current
treatment are not included. Patients receiving special treatment (experimental or palliative, for
example) are not included.
All types of acute leukemia listed under 8.3 in the ICD-10 codes are included. Other types may be
included upon approval from the IUK.
It is possible to include only AML patients and not track patients with ALL.
ONKO-KISS_AL data are entered into a separate databank and evaluated separately. AML and
ALL patients are also evaluated separately. Data are also evaluated by therapy group.
A data collection form should be completed for each neutropenic phase.
Because the risk of infection increases with each (successive) neutropenic phase, how many
times the patient has already been neutropenic is also recorded. The phases should be numbered
DRAFT VERSION
20
chronologically, and the number of the phase should be noted. In this way it is possible to evaluate
in which neutropenic phase a patient developed an infection. Because this information is very
important, it must be determined when a patient’s medical history is taken if and how many times
he or she has already been neutropenic. Neutropenic phases are counted starting once leukemia
has been diagnosed. If the course of sickness is unknown because of stays in other hospitals,
then it is necessary and important to ask the previously attending physicians about the number of
prior cycles or to determine this information from referral letters. Every cycle of neutropenia is
should be given a new number. This information must not be collected about patients being
treated with a relapse protocol.
The phases of treatment are classified in the following table:
Chemotherapy phase Therapy block No.
Preliminary phase 0
Induction 1 1
Induction 2 2
Reinduction 1 3
Reinduction 2 4
Consolidation 1 5
Consolidation 2 6
Consolidation 3 7
Consoldiation 4 8
Consolidation 5 9
Induction 1 and 2 10
Reinduction 1 and 2 11
Consolidation 1 and 2 12
Consolidation 6 13
Consolidation 7 14
Preliminary phase and induction 1 15
Induction 3 16
Preliminary phase, induction 1 and 2 17
Induction, phase unknown (1, 2, or 1 and 2) 18
Patients are divided into four therapy groups by the type of chemotherapy given for the purpose of
risk stratification when the data are evaluated twice yearly.
Standard therapy
Expanded therapy
Relapse therapy
Therapy for patients >60
The therapy block numbers (from the above table) are sorted into the therapy groups “standard
therapy” and “expanded therapy” as follows.
Therapy groups (AML) Therapy block no.
Standard therapy 0, 1, 2, 5, 10, 15, 17, 18 Expanded therapy 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 16 Relapse therapy Patients >60
Therapy groups (ALL) Therapy block no.
Standard therapy 0, 1, 2, 3, 4, 5, 6, 10, 11, 12, 15, 17, 18
DRAFT VERSION
21
Expanded therapy 7, 8, 9, 13, 14, 16 Relapse therapy Patients > 60
Patients being treated according to a relapse therapy plan are not sorted into therapy groups. Only
the fact that the patients are being treated by a relapse therapy plan is noted.
Patients 61 and older are also not sorted into therapy groups. As with patients in relapse therapy,
this group is evaluated separately.
Patients in relapse therapy and patients 61 and over should still be classified by therapy block,
although they are not included in “standard” or “expanded” therapy groups.
The specific type of therapy undergone by a patient is not recorded on the patient information form
or in webKess.
Instead, participating departments are required to answer an annual questionnaire about by which
kinds of therapy their AML and ALL patients receive.
7.2 Patient progress form
The patient progress form has been developed as an aid to HAI surveillance. Fevers, microbiological
or radiological evidence and changes to antibiotic therapy can be noted here when patient records are
examined, in order to ease the diagnosis of healthcare-associated BSI or pneumonia.
Questions about the pneumonia or BSI diagnosis can be directed to the IUK.
7.3 BSI pathogen resistance surveillance
The resistograms of proven BSI disease agents (all pathogens except skin contaminants) should be
sent upon their appearance per fax to the IUK in Freiburg.
The resistograms must be clearly identified with ONKO-KISS hospital abbreviation, the module and
the patient’s webKessID.
These data are collect in a databank and evaluated.
DRAFT VERSION
22
8. Documentation specifications
8.1 Patient information form
Hospital abbreviation Assigned by the NRZ upon registration for webKess. If the hospital
already has an abbreviation because of participation in another module,
it will be used further.
Patient ID Automatically assigned during data entry.
Underlying illness See 8.2 for list of abbreviations of underlying illnesses
Transplantation Sygenic transplantation is considered “ allogeneic/related” for the
purposes of surveillance.
Pathogen See 8.4 for list of pathogen abbreviations
ICD-10 codes for ONKO-
KISS_AL
See 8.3 for list of acute leukemias
8.2 Abbreviations of underlying illnesses
Acute myeloid leukemia AML
Chronic myeloid leukemia CML
Acute lymphoblastic
leukemia
ALL
Non-Hodgkin’s lymphoma NHL
Myelodysplastic syndrome MDS
Plasma cell myeloma PLAS
All other illnesses AND
8.3 ICD-10 codes for acute leukemias
C91.0 C91.5 C91.7 C91.9
C92.0 C92.2 C92.4 C92.5 C92.7 (following consultation) C92.9
C93.0 C93.2 C93.7 C93.9
C94.2 C94.3 C94.7
C95.0 C95.2 C95.7 C95.8 C95.9
DRAFT VERSION
23
8.4 Pathogen abbreviations
Please differentiate as exactly as possible. For technical reasons, the abbreviations have been left in
the German original and may seem unrelated to the English name of the pathogen.
Pathogen Pathogen group
No growth KW KW
Gram-positive pathogens
Other gram-positive pathogens APS GPST
Other cocci ANK ANK
Bacillus spp. BAL GPST
Cornebacterium spp. COR GPST
Enterococci ENT ENT
Enterococcus faecalis ÊFIS ENT
Enterococcus faecium EFUM ENT
Vancomycin-resistant Enterococcus VRE VRE
Vancomycin-resistant Enterococcus faecalis VFIS VRE
Vancomycin-resistant Enterococcus faecium VFUM VRE
Coagulase-negative Staphylococcus KNS KNS
Staphylococcus epidermidis SEPI KNS
Staphylococcus haemolyticus SHAE KNS
Staphylococcus hominis SHOM KNS
Staphylococcus lugdunensis SLUG KNS
Micrococci MIK ANK
Nocardia NOC GPST
Propionibacterium PPB GPST
Staphylococcus aureus SAU SAU
Methicillin-resistant Staphylococcus aureus MRSA MRSA
Streptococci STR STR
Group A Streptococci STRA STR
Group B Streptococci STRB STR
Streptococcus equismilis (C and G) STRE STR
Streptococcus mitis STRM STR
Streptococcus pneumonia STRP STR
Viridan streptococcus STRV STR
Gram-negative pathogens
Other gram-negative pathogens AGNE AGNE
Acinetobacter spp. ACI ACI
DRAFT VERSION
24
Other enterobacteria AEN AEN
Other gram-negative bacilli ANS ANS
Other gram-negative ESBL bacilli ANS_ESBL ANS_ESBL
Other gram-negative MBL bacilli* ANS_MBL ANS_MBL
Other non-fermenter ANO ANO
Bacteroides spp. BAC BAC
Burkholderia cepacia BCE BCE
Citrobacter spp. CIT CIT
Citrobacter spp., ESBL CIT_ESBL CIT_ESBL
Citrobacter spp., MBL* CIT_MBL CIT_MBL
Enterobacter spp. ENB ENB
Enterobacter spp., ESBL ENB_ESBL ENB_ESBL
Enterobacter spp., MBL* ENB_MBL ENB_MBL
Escherichia coli ECO ECO
Escherichia coli, ESBL ECO_ESBL ECO_ESBL
Escherichia coli, MBL* ECO_MBL ECO_MBL
Haemophilus spp. HAE HAE
Klebsiella spp. KLE KLE
Klebsiella spp., ESBL KLE_ESBL KLE_ESBL
Klebsiella spp., MBL* KLE_MBL KLE_MBL
Moraxella catarrhalis MOR MOR
Neisseria spp. NEI NEI
Proteus spp. PRO PRO
Proteus spp., ESBL PRO_ESBL PRO_ESBL
Proteus spp., MBL* PRO_MBL PRO_MBL
Pseudomonas aeruginosa PAE PAE
Pseudomonas aeruginosa, MBL* PAE_MBL PAE_MBL
Serratia spp. SER SER
Serratia spp., ESBL SER_ESBL SER_ESBL
Serratia spp., MBL SER_MBL SER_MBL
Stenotrophomonas maltophilia STM STM
Always include resistance to ESBL!
*Metallo-betalactamase- and carbapenemase-producing pathogens are included in the abbreviation
MBL.
Pathogen Pathogen group
Other pathogens
Other anaerobes ANA ANA
Atypical mycobacteria AMY AMY
DRAFT VERSION
25
Atypical pneumonia pathogens
Chlamydia spp. CHL CHL
Legionella spp. LEG LEG
Legionella antigens LEG_AG ÖEG
Legionella antibodies LEG_AK LEG
Mycoplasma MPL MPL
Fungi
Aspergillus spp. ASP ASP
Aspergillus antibodies ASP_AG ASP
Aspergillus flavus AFL ASP
Aspergillus fumigates ASF ASP
Aspergillus nidulans ANI ASP
Aspergillus niger ASN ASP
Aspergillus terreus ATE ASP
Candida spp. ANC ANC
Candida albicans CAN ANC
Candida glabrata CGLA ANC
Candida krusei CKRU ANC
Candida parapsilosis CPAR ANC
Candida tropicalis CTRO ANC
Candida guiellermondi CGUI ANC
Candida kefi CKEF ANC
Candida norvegensis CNOR ANC
Candida inconspicua CINC ANC
Hyphae or other parts of fungus* HYPH SCH
Acremonium spp. ACRE SCH
Absidia spp. ABS SCH
Exophiala spp. EXO SCH
Fusarium spp. FUS SCH
Mucor spp. MUC SCH
Penicillium spp. PEN SCH
Pseudoallescheria spp. PSE SCH
Rhizopus spp. RHI SCH
Sedosporium spp. SED SCH
Other funguss SPA SCH
Cryptococcus spp. CRY HEF
Geotrichum spp. GEO HEF
Trichosporon TRI HEF
Other yeasts HPA HEF
DRAFT VERSION
26
Pneumocystis jirovecii PCC PCC
Other fungi ANP ANP
*for fungal pneumonia surveillance
Viruses
Adenovirus ADV ADV
Other viruses ANV ANV
Cytomegalie virus CMV CMV
Enterovirus ENV ENV
Human metapneumovirus HMV HMV
Herpes simplex HSV HSV
Influenza / parainfluenza INV INV
Respiratory syncytial virus RSV RSV
Rhinovirus RHV RHV
Pathogens are presented in the evaluation summarized in groups.
DRAFT VERSION
27
8.5 Examples for determining neutropenia as a surveillance period
(In these examples, L= total leukocytes per mm3. In reference to neutrophil granulocytes, the
relevant limit value is 500/mm3.)
1.
In this case, the patient is considered continuously neutropenic, because the leukocyte count was
>1000/ mm3 for only two consecutive days rather than three, as required. As a result, 7 neutropenia-
days are recorded. Infections are recorded from day 2.
2.
In this case, the patient is considered neutropenic starting on day 5 because the leukocyte count was
< 1000 mm3 for only one day (on day 2) and not for two consecutive days, as required. Three
neutropenia-days are recorded from day 5. Infections are recorded from day 6.
3.
In this case, the patient is considered neutropenic starting on day two because the leukocyte count
was < 1000 mm3 on two consecutive days. Day 4 is also considered a neutropenia day because the
leukocyte count was not >1000 mm3 for three consecutive days, as required. 6 neutropenia-days are
recorded, and infections are recorded from day 3.
4.
In this case, the patient is considered neutropenic until day 3. The patient is no longer neutropenic
from day 4. As a result, 3 neutropenia-days are recorded. Infections are recorded from day 2 to day 5.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
200 L 600 L 1000 L 1200 L 1200 L 800 L 400 L
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1400 L 800 L 1200 L 1100 L 600 L 200 L 100 L
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1400 L 800 L 1000 L 1100 L 600 L 200L 100L
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
200 L 800 L 1000 L 1100 L 1800 L 2600 L 5400 L
DRAFT VERSION
28
5.
In this case, the patient is considered from day 3 to 5 not neutropenic and neutropenic on days 1 and
2 and from day 6. Days 3 to 5 are not counted as neutropenia-days, and 4 neutropenia-days are
recorded for the patient. Infections are recorded from day 2 to 4 (including day 4) and from day 7.
Infections appearing on days 5 and 6 are not recorded.
This situation is highly unlikely and has been presented here only for the sake of completeness.
More likely is a situation in which a patient is neutropenic in two clearly different phases.
A final example:
6.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
200 L 800 L 1000 L 1500 L 2100 L 4500 L 6200 L
Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14
5200 L 5800 L 5200 L 3500 L 1800 L 800 L 200 L
The first phase of neutropenia lasts until day 3. The second phase starts on day 13. The neutropenia-
days of both phases are counted together, with the result of 5 neutropenia-days for the patient.
Infections are recorded from day 2 to day 5 and from day 14. Infections that appear between day 6
and day 13 are not recorded.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
200 L 800 L 1200 L 1500 L 1100 L 800 L 200 L
DRAFT VERSION
29
9 References
1. Carlisle P et al.: Nosocomial infections in neutropenic cancer patients, Infect Control
Hosp Epidemiol 1993, 6: 320-324
2. Dettenkofer M et al.: Nosokomiale Infektionen bei neutropenischen Patienten auf einer
KMT-Station, 4. Berliner Workshop: Nosokomiale Infektionen bei
immunsupprimierten Patienten, Berlin 2000
3. Dettenkofer M, Ebner W, Bertz H et al.: Surveillance of Nosocomial Infections in Adult
Recipients of Allogeneic and Autologous Bone Marrow and Peripheral Blood
Stem-Cell Transplantation. Bone Marrow Transplantation 2003; 31:795-801
4. Dettenkofer M, Wenzler-Röttele S, Babikir R, Bertz H, Ebner W, Meyer E, Rüden H,
Gastmeier P, Daschner F D: Surveillance of nosocomial sepsis and pneumonia in
patients with a bone marrow or peripheral blood stem cell transplantation. A
multicenter project. Clin Infect Dis 40, 926-931, 2005
5. Laws H J, Kobbe G, Dilloo D, Dettenkofer M, Meisel R, Geisel R, Haas R, Gobel U,
Schulze-Robbecke R: Surveillance of nosocomial infections in paediatric
recipients of bone marrow or peripheral blood stem cell transplantation during
neutropenia, compared with adult recipients. J Hosp Infect Oct 18, 2005
DRAFT VERSION
30
10 Appendix
10.1 Patient data collection form for ONKO-KISS and ONKO-KISS_PAED: Patients with bone marrow or blood stem cell transplantations (BMT, PBSCT, cord blood) Last name: First name:
Birthdate: Date of admission:
Hospital: webKess ID: Gender f m Birth year:
1st
Neutropenic phase: from (date) ____________ to _______________
2nd
Neutropenic phase: from (date) ____________ to _______________
Patient was neutropenic upon admission to ward: Yes No
Surveillance ended by: end of neutropenic phase transfer/discharge death
Basic illness AML CML ALL NHL MDS PLAS AND
Current stage Early Late
Transplantation KMT PBSCT Cord blood
autologous autologous
allogeneic, related allogeneic, related allogeneic, related
allogeneic, unrelated allogeneic, unrelated allogeneic, unrelated
Quinolone prophylaxis (i.e., Levofloxacin or Ciprofloxacin) Yes No
If no, why? No routine quinolone prophylaxis Quinolone prophylaxis is
routine, but patient already under antibiotic
Type of access CVC Hickman Port No central access
If CVC: Site of access? Jugular Subclavian Other type
Type of CVC? Uncoated Coated (silver) Coated (anti-infective)
Use of skin disinfectants with remanence effects? Yes No
If Yes: Octenidin Chlorhexidin other_____________
Upon CVC insertion: Yes No unknown
For catheter care: Yes No unknown
Use of patches/bandages with remanence effects? Yes No
If Yes: Biopatch Tegaderm CHG/Chlorhexidin other ____________
Patient in ICU No Yes from (date) _______________ ventilated? Yes No
BSI: Yes No
Date: ___________ Pathogen: ________
Pneumonia: Yes No
Date: ___________ Microbiological examination of sample? Yes No
Pathogen: ________ Found in ________________
Version 06_2011
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
31
10.2 Patient data collection form for ONKO-KISS_AL: Patients with AML or ALL
without primary transplantation and receiving standard chemotherapy
Last name: First name:
Birthdate: Date of admission:
Hospital: webKess ID: Gender f m Birth year:
Current stay:
Neutropenic phase No.: ______ from (date) ________ to (including) ____________
Patient was neutropenic upon admission to ward: Yes No
Surveillance ended by: end of neutropenic phase transfer/discharge death
Basic illness AML ALL
Current stage Early Late
Chemotherapy Phase __________________________ (see surveillance protocol)
Quinolone prophylaxis (i.e., Levofloxacin or Ciprofloxacin) Yes No
If no, why? No routine quinolone prophylaxis Quinolone prophylaxis
is routine, but patient already under antibiotic
Type of access CVC Hickman Port No central access
If CVC: Site of access? Jugular Subclavian Other type
Type of CVC? Uncoated Coated (silver) Coated (anti-infective)
Use of skin disinfectants with remanence effects? Yes No
If Yes: Octenidin Chlorhexidin other_____________
Upon CVC insertion: Yes No unknown
For catheter care: Yes No unknown
Use of patches/bandages with remanence effects? Yes No
If Yes: Biopatch Tegaderm CHG/Chlorhexidin other ____________
Patient in ICU No Yes from (date) _______________ ventilated? Yes No
BSI: Yes No
Date: ___________ Pathogen: ________
Pneumonia: Yes No
Date: ___________ Microbiological examination of sample? Yes No
Pathogen: ________ Found in ________________
Version 06_2011
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
32
10.3 Data collection forms for pneumonia
Data collection form for normal pneumonia
Patient ONKO-KISS ID: _________________________
Diagnosis criteria (fill out for each case of pneumonia registered)
Evidence from single X-ray Yes No
Evidence from multiple X-rays Yes No
Evidence from single CT Yes No
Evidence from multiple CT Yes No
Fever > 38oC Yes No
Sputum Yes No
Coughing Yes No
Dyspnea Yes No
Crackling sounds Yes No
Pleural rub Yes No
Version 06_2010
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
33
Data collection form for Fungal Pneumonia
Patient ONKO-KISS ID: ______________________________
Demonstrated invasive fungal pneumonia
Histo/Zytopathology: (Proof of hyphae in tissue): Yes No
Culture of tissue from primarily sterile body sites: Yes No
Probable invasive fungal pneumonia
At least one of the following patient characteristics
Neutropenia > 10 days Yes No
Post status PBSCT or BMT: Yes No
Corticosteroid treatment > 3 weeks Yes No
T-cell immunosuppressive medication Yes No
Congenital immunodeficiency Yes No
At least one of the following mycological findings
Culture evidence of fungus Yes No
HYPH Evidence of fungal parts Yes No
ASP_AG Positive evidence of aspergillus AG in BAL or serum Yes No
At least one of the following findings in thoracic CT
Thick nodules with or without halos Yes No
Air crescents Yes No
Cavity development Yes No
Version 08_2010
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
34
Data collection form for Legionella pneumonia
Patient ONKO-KISS ID: _____________________
At least one of the following signs confirmed by thoracic X-ray
New or progressive and persistent infiltrate Yes No
Consolidation Yes No
Cavity formation Yes No
Pneumatoceles, in infants <1 year old Yes No
At least one of the following:
Fever (38C) Yes No
Confusion without other cause in adults >70 years old Yes No
New purulent sputum Yes No
New cough or dyspnea or tachypnea
Yes No
Rales
or bronchial breath sounds Yes No
Worsening gas exchange Yes No
Hemoptysis Yes No
Pleural pain Yes No
And at least one of the following:
LEG Culture evidence or IF test Yes No
LEG_AG Evidence L.pneumophila AG in urine Yes No
LEG_AK Repeated quadrupling of antibody titer to > 1:128 Yes No
Version 08_2010
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
35
10.4 Progress form for infection surveillance, Hematological /Oncological Units
(Example)
Patient:
Date Leukocytes Fever X-ray/ CT Pulmonary findings Microbio
Version 03_2011
Institute for Environmental Medicine and Hospital Hygiene, University Clinic Freiburg
National Reference Center for Surveillance of Nosocomial Infections, Berlin
DRAFT VERSION
36
11 Legal Notice
National Reference Center (NRZ) for Surveillance of Nosocomial Infections (Director: Prof. Petra Gastmeier, MD) Charité-University Medicine Berlin A joint institution of Freie Universität Berlin und Humboldt Universität zu Berlin Hindenburgdamm 27 12203 Berlin Tel.: 030/8445 3680 Fax: 030/8445 3682 www.nrz-hygiene.de Technical Support, including webKess: Tel. 030/ 8445 3680 e-mail: [email protected] Partner Prof. Markus Dettenkofer, MD Institute for Environmental Medicine and Hospital Hygiene University Clinic Freiburg Breisacher Str. 115 B 79106 Freiburg Tel.: 0761/270 82750 Fax: 0761/270 82030 Robert Koch-Institut (RKI) Abteilung für Infektionskrankheiten, FG 14: Angewandte Infektions- und Krankenhaushygiene (Prof. Martin Mielke, MD) Nordufer 20 13353 Berlin Tel.: 030/4547 2233 Fax: 030/4547 2612
ONKO-KISS Contact
Institut für Umweltmedizin und Krankenhaushygiene
Albert Ludwigs-Universität Freiburg
Breisacherstraße 115 b – 79106 Freiburg
Prof. Markus Dettenkofer, MD (Project leader)
Tel.: 049 761/270 827/50 · Fax: 049 761/270 82530
E-mail: [email protected]
Regina Babikir (administration, organization, surveillance questions)
Tel.: 049 761/270-82750 · Fax: 0761/270-82030 E-mail: [email protected]
Last update: October 2012